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i APPLICATION FOR PERMITy SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 12�" Telephone 12091 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED . (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for we91 pump and the Rules and Regulations of the San Joaquin Local Health District. F n r2. �� , �ja? � 0 Cit Lot Size PM Job Address I Owner's Name t l S�.✓�u//`✓� Address % �� C Phone Contracto ii! Address License Ng.� 7$ Phone G ... TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing p4ro"mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -S Specifications r-1 Public CI Other' ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _ALA__ H•P-i3 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION {.I REPAIR/ADDITION [ I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of,living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ „."1Method of Disposal Distance to nearest: Well, Foundation Property Line li Total length/size 'i LEACHING LINE ❑ No. & Length of lines FILTER BED' El Distance.to nearest: Wel! Foundation Property Line 1 e s SEEPAGE PITS l 1 Depth "I Size _ Number i SUMPS ❑ Distancetonearest: Well Foundation Property Line .1 � DISPOSAL PONDS ❑ I her certify that I have prepared this application and that the work will-ba done in accordance with San Joaquin county ordinances, state laws, and i` rules and regulations of the San Joaquin Local Health District. ` Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus II for 11 uired inspection ..Complete drawing on reverse side. Signe X �--- Title:_ �5 -- Date: T � R D ARTMENT UE ONLY 0� Application Accepted by Date �� Area 7'h - - IS Pit or Grout Inspection by ' Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO r E `I r EH 1324 iREV.F/K51 < EH 14-29